The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?
- A. Pureed canned squash
- B. Pureed apples
- C. Yogurt
- D. Infant rice cereal
Correct Answer: D
Rationale: Infant rice cereal is recommended as a first solid food due to its digestibility and added iron, suitable for infants starting solids.
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When performing an abdominal assessment, what is the correct order of the tasks?
- A. inspect, percuss, palpate, auscultate
- B. inspect, palpate, percuss, auscultate
- C. inspect, auscultate, percuss, palpate
- D. inspect, palpate, auscultate, percuss
Correct Answer: C
Rationale: In an abdominal assessment, percussing or palpating prior to auscultating can alter the bowel sounds and influence findings.
Which type of physician should this client be encouraged to see?
- A. a radiologist
- B. a gynecologist
- C. a physiatrist
- D. an oncologist
Correct Answer: B
Rationale: A gynecologist specializes in the female reproductive system and is best suited to address postmenopausal bleeding, which may indicate conditions like endometrial cancer or hormonal imbalances. A radiologist evaluates imaging, a physiatrist focuses on rehabilitation, and an oncologist treats cancer, but a gynecologist is the primary specialist for this issue.
A client has a nasogastric (NG) tube in place following abdominal surgery. The purpose of this tube immediately following surgery is to:
- A. simplify medication administration
- B. measure accurate input and output
- C. prevent accumulation of fluids and gas
- D. facilitate collection of specimens
Correct Answer: C
Rationale: Postoperative NG tubes decompress the stomach, preventing fluid and gas buildup that could disrupt surgical sites or cause vomiting.
The nurse learns at shift report that the immobile client has bilateral foot drop. Which finding during the nurse's assessment supports the presence of foot drop?
- A. The client's great toe is dorsiflexed, and the other toes are fanned out.
- B. The client's feet are unable to be maintained perpendicular to the legs.
- C. The client is unable to move the feet into a position of plantar flexion.
- D. The client is only able to dorsiflex both feet when asked to bend the feet.
Correct Answer: B
Rationale: B: Inability to hold feet perpendicular indicates foot drop. A: This describes a Babinski sign. C: Foot drop involves persistent plantar flexion, not inability to plantar flex. D: Foot drop prevents dorsiflexion.
A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction?
- A. calcium
- B. magnesium
- C. potassium
- D. sodium chloride
Correct Answer: D
Rationale: Duodenal intestinal fluid is rich in K+, Na+, and bicarbonate. Suctioning to remove excess fluids decreases the client's K+ and Na+ levels.